MCPHS University Health Insurance Program Information Beginning September 1, 2018

Health Services MCPHS University students on the Boston campus have access to the Massachusetts College of Art and Design Student Health Services (Optum Health Services), second floor of the new Mass Art Residence Hall, 578 Huntington Avenue (617-879-5220) by utilizing their personal health insurance and scheduling appointments. Blue Cross and Blue Shield is accepted at the Mass Art Student Health Services.

Health services for Worcester, Manchester, and Newton campus students are available through the many providers in the local area.

Health Insurance Waiver and Enrollment Information:

According to the Commonwealth of Massachusetts and MCPHS University policy, all Boston, Worcester, Manchester, and Newton matriculated students (regardless of enrollment) must be covered by a comprehensive health insurance program. MCPHS University is obligated by law to ensure that students meet this requirement. Any student who does not meet this obligation may obtain coverage through the Blue Cross and Blue Shield Student Health Insurance Plan, an alternative program arranged by the college and administered through University Health Plans.

All Boston, Worcester, Newton and Manchester matriculated students (regardless of enrollment) will be charged $2,595 for the annual student insurance plan. If you have a comprehensive health insurance plan for the 2018-2019 academic year, you may complete the online waiver at www.universityhealthplans.com. The health insurance charge will be removed from your student account only after a valid, completed waiver has been submitted.

Any Boston, Worcester, Newton or Manchester student who does not submit proof of enrollment in a qualifying program before September 25, 2018 will automatically be enrolled in and charged for the Student Health Insurance Plan. Once enrolled, waiving the insurance is not an option. No exceptions or refunds will be granted. Please note that international students must enroll in the Plan with the exceptions of: 1) Those international students whose sponsoring institutions have a signed agreement with MCPHS University that complies with the University’s health insurance waiver requirements or 2) International students with a plan for which their health insurance company’s primary office is based in the United States AND the policy provides comparable coverage to the University Student Health Insurance Plan. Travel Insurance Plans and Short-Term Limited Duration Plans are not comparable. ISO and PSI plans are popular travel insurance plans that do not provide comprehensive coverage. Students should not waive with these types of plans are they are not comparable to the Student Health Insurance Plans. International students who do not fall under conditions 1 or 2 above MUST purchase the University’s Student Health Insurance Plan. Additionally, online only students are not eligible for the student health insurance plan.

For questions addressing BCBS general information, or if you do not have internet access, please contact University Health Plans at (800) 437-6448. If you have questions regarding the benefits please feel free to contact Blue Cross and Blue Shield of Massachusetts at (888) 753-6615. If you have questions about the $2,595 premium that has been charged to your bill, please contact MCPHS University at (617) 732-2864.

Student Health Insurance Policy Periods and Premium Rates

Annual Fall Spring Summer (9/1/18-8/31/19) (9/1/18-12/31/18) (1/1/19-8/31/19) (5/1/19-8/31/19) Student $2,595 $869 $1,732 $869

Insurance coverage for dependents is available. Dependent enrollment starts and ends concurrently with that of the student, unless the student is enrolling a newborn baby or if the student’s dependent experienced a qualifying event. If you are interested in insurance for dependents, please contact University Health Plans for additional information.

Dependent Enrollment Forms will be available online at www.universityhealthplans.com for you to print, fill out, and submit to University Health Plans. SUMMARY OF BENEFITS

Blue Care Elect® Preferred 80 With Copayment Student Health Plan 2018 - 2019

MCPHS

This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law.

An Association of Independent Blue Cross and Blue Shield Plans Your Choice Your Deductible Telehealth Services Your deductible is the amount of money you pay out-of-pocket each You are covered for certain medical and behavioral health services for plan year before you can receive coverage for most benefits under this conditions that can be treated through video visits from an approved plan. If you are not sure when your plan year begins, contact Telehealth provider. These Telehealth services are available by Blue Cross Blue Shield of Massachusetts. Your deductible is $300 using your computer or mobile device when you prefer not to per member for in-network and out-of-network services combined. make an in-person visit for any reason to a doctor or therapist. For a list of Telehealth providers, visit the Blue Cross Blue Shield of When You Choose Preferred Providers Massachusetts website at www.bluecrossma.com; consult the You receive the highest level of benefits under your health care plan Provider Directory; or call the Physician Selection Service at when you obtain covered services from preferred providers. These are 1-800-821-1388. called your “in-network” benefits. See the charts for your cost share. Note: If a preferred provider refers you to another provider for Utilization Review Requirements covered services (such as a lab or specialist), make sure the provider Certain services require pre-approval through Blue Cross is a preferred provider in order to receive benefits at the in-network Blue Shield of Massachusetts for you to have benefit coverage, this level. If the provider you use is not a preferred provider, you’re still includes non-emergency and non-maternity hospitalization and may covered, but your benefits, in most situations, will be covered at the include certain outpatient services, therapies, procedures (such as out-of-network level, even if the preferred provider refers you. MRIs and CT Scans), and drugs. You should work with your provider to determine if pre-approval is required. If your provider, or you, do How to Find a Preferred Provider not get pre-approval when it is required, your benefits will be reduced There are a few ways to find a preferred provider: or denied, and you may be fully responsible for payment to the • Look up a provider in the Provider Directory. If you need a copy of service provider. Refer to your subscriber certificate for requirements your directory, call Member Service at the number on your ID card. and the process you should follow for Utilization Review, including Pre-Admission Review, Pre-Service Approval (for certain outpatient • Visit the Blue Cross Blue Shield of Massachusetts website at services), Concurrent Review and Discharge Planning, and Individual www.bluecrossma.com/findadoctor Case Management. • Call the Physician Selection Service at 1-800-821-1388 Dependent Benefits When You Choose Non-Preferred Providers This plan covers dependents until the end of the calendar month You can also obtain covered services from non-preferred providers, in which they turn age 26, regardless of their financial dependency, but your out-of-pocket costs are higher. These are called your student status, or employment status. See your subscriber certificate “out-of-network” benefits. See the charts for your cost share. (and riders, if any) for exact coverage details.

Payments for out-of-network benefits are based on the Blue Cross Pediatric Essential Dental Benefits Blue Shield allowed charge as defined in your subscriber certificate. Your medical plan coverage includes a separate dental policy that covers You may be responsible for any difference between the allowed pediatric essential dental benefits for members until the end of the charge and the provider’s actual billed charge (this is in addition to calendar month in which they turn age 19 as required by federal law. your deductible and/or your coinsurance). You must meet a plan-year deductible for certain covered dental Your Out-of-Pocket Maximum services. Your deductible is $50 per member (no more than $150 for Your out-of-pocket maximum is the most that you could pay during three or more members enrolled under the same family membership). a plan year for deductible, copayments (including prescription drug Your out-of-pocket maximum is the most that you could pay during copayments), and coinsurance for covered services. Your a plan year for deductible and coinsurance for covered dental out-of-pocket maximum is $6,850 per member (or $13,700 per services. Your out-of-pocket maximum is $350 per member family) for in-network and out-of-network services combined. (no more than $700 for two or more members enrolled under Emergency Room Services the same family membership). In an emergency, such as a suspected heart attack, stroke, or To find participating dental providers, visit the Blue Cross Blue Shield poisoning, you should go directly to the nearest medical facility of Massachusetts website at www.bluecrossma.com/findadoctor or or call 911 (or the local emergency phone number). You pay a call the Physician Selection Service at 1-800-821-1388. copayment for in-network or out-of-network emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your cost share. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based Nothing, no deductible 20% coinsurance after deductible schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year age 3 and older Routine adult physical exams, including related tests Nothing, no deductible 20% coinsurance after deductible (one per calendar year) Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $2,000 per ear every 36 months for a member age All charges beyond the maximum, 20% coinsurance after deductible and 21 or younger) no deductible all charges beyond the maximum Routine vision exams (one every 24 months, except one every Nothing, no deductible 20% coinsurance after deductible 12 months until the end of the month a member turns age 19) Vision supplies (one set of prescription lenses and/or frames or 35% coinsurance after deductible 55% coinsurance after deductible contact lenses per calendar year until the end of the month a member turns age 19) Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $250 per visit, no deductible $250 per visit, no deductible (waived if admitted or for (waived if admitted or for observation stay) observation stay) Clinic visits; physicians’ and podiatrists’ office visits $35 per visit, no deductible 20% coinsurance after deductible Chiropractors’ office visits $35 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $35 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational $35 per visit, no deductible 20% coinsurance after deductible (up to 100 visits for rehabilitation services and 100 visits for habilitation services per calendar year*) Speech, hearing, and language disorder treatment–speech therapy $35 per visit, no deductible 20% coinsurance after deductible Diagnostic tests • Lab tests and other tests Nothing, no deductible 20% coinsurance after deductible • X-rays $5 per service date, no deductible 20% coinsurance after deductible • CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $250 per category per service date 20% coinsurance after deductible after deductible Home health care and hospice services 20% coinsurance after deductible 40% coinsurance after deductible Oxygen and equipment for its administration 20% coinsurance after deductible 40% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds 20% coinsurance after deductible** 40% coinsurance after deductible** Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia • Office and health center services $35 per visit***, no deductible 20% coinsurance after deductible • Hospital and other day surgical facility services 20% coinsurance after deductible 40% coinsurance after deductible Inpatient Care (including maternity care) General or chronic disease hospital care 20% coinsurance after deductible 40% coinsurance after deductible (as many days as medically necessary) Mental hospital or substance abuse facility care 20% coinsurance after deductible 40% coinsurance after deductible (as many days as medically necessary) Rehabilitation hospital care (up to 60 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth (20% coinsurance after deductible for out-of-network). *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Prescription Drug Benefits* Your Cost In-Network** Your Cost Out-of-Network At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $20 for Tier 1 $30 for Tier 2 $50 for Tier 3 Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $40 for Tier 1*** $60 for Tier 2 $100 for Tier 3 * Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. *** Certain generic medications are available through the mail service pharmacy at $9. For more information, go to www.bluecrossma.com/mail-service-pharmacy.

Pediatric Essential Dental Benefits* Your Cost In-Network** Group 1–Preventive and Diagnostic Services: oral exams, X-rays, and routine dental care Nothing, no deductible Group 2–Basic Restorative Services: fillings, root canals, stainless steel crowns, periodontal care, 25% coinsurance after deductible oral surgery, and dental prosthetic maintenance Group 3–Major Restorative Services: tooth replacement, resin crowns, and occlusal guards 50% coinsurance after deductible Orthodontic Services: medically necessary orthodontic care pre-authorized for a qualified member 50% coinsurance, no deductible * All covered services are limited to members until the end of the month they turn age 19, and may be subject to an age-based schedule or frequency. For a complete list of covered services or additional information, refer to your subscriber certificate. ** There are no out-of-network benefits for dental services.

Get the Most from Your Plan Visit us at www.studentbluema.com or call 1-888-753-6615 to learn about discounts, savings, resources, and special programs available to you, like those listed below.

A Fitness Benefit toward membership at a health club or for fitness classes Reimbursement for membership fees for up This fitness benefit applies for fees paid to: privately‑owned or privately‑sponsored health clubs or fitness facilities, to 3 consecutive months of one annual family including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness or individual membership at a health club or centers. (See your subscriber certificate for details.) 10 fitness classes, per individual or family per calendar year A Weight Loss Program Benefit toward participation in a qualified weight loss program Reimbursement for up to 3 months This weight loss program benefit applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross participation fees per individual or family Blue Shield of Massachusetts designated weight loss program. (See your subscriber certificate for details.) per calendar year Blue Care Line®—A 24-hour nurse line to answer your health care questions—call 1-888-247-BLUE (2583) No additional charge

Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-888-753-6615, or visit us online at www.studentbluema.com. Interested in receiving information from us via e-mail? Go to www.studentbluema.com to sign up.

Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 184370CE (04/18) PDF LC Nondiscrimination Notice

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected].

If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online atocrportal.hhs.gov ; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 164264M 55-1487 (8/16) Translation Resources Proficiency of Language Assistance Services

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的号码联系会员服务部（TTY 号码：711）。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711). Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711). Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711). :ةيرب/Arabic انتباه: إذا كنت تتحدث اللغة العربية، فتتوفر خدمات املساعدة اللغوية ا مجانًبالنسبة لك. اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ُهويتك )جهاز الهاتف النيص للصم والبكم “TTY”: 711(. Mon-Khmer, Cambodian/ : ខ្揂រ ζរជូនដំណឹង៖ ប䮚សិនប�ើអ䮓កនិ架យ徶羶 ខ្揂រ សេ玶ជំនួយ徶羶ឥតគិតថ្濃 គឺ讶ចរក厶នសម殶ប់អ䮓ក។ សូមទូរស័ព䮑ទៅផ្នកសេ玶សមជិក㾶មលេខ (TTY: 711) នៅល�ើប័ណ䮎សមஶ ល់ខ្លនរបស់អ䮓ក ។ French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré (TTY : 711). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa (TTY: 711). Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711). Hindi/हिंदी: ध्봾न दᴂ: यदि आप हिन्饀 बोलते हℂ, तो भाषा सहायता सेवाएँ, आप के लिए नि:शुल् उपलब㔧 हℂ। सदस् सेवाओं को आपके आई.डी. कार 㔡 पर दिए गए नंबर पर कॉल करᴂ (टी.टी.वाई.: 711). Gujarati/ગુજરાતી: ધ્뺾ન આપો: જો તમે ગુજરાતી બોલતા હો, તો તમને ભાષાકીય સહાયતા સેવાઓ વિના મૂલ્ય ઉપલબ㚧 છે. તમારા આઈડી કાર㚡 પર આપેલા નંબર પર Member Service ને કૉલ કરો (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card (TTY: 711). Japanese/日本語 : お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください（TTY: 711）。 German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an (TTY: 711). :پارسیان/Persian توج: اگر زبان شما فارسی است، خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد. با شمار تلفن مندرج بر روی کارت شناسایی خود با بخش »خدمات اعضا« تماس بگیر ید )TTY: 711(. Lao/ພາສາລາວ: ໍຂ້ ຄວນໃສ່ ໃຈ: ຖ້ າເຈົ້ າເວົ້ າພາສາລາວໄດ້ , ີມການບໍ ິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ ່ໍບເສຍຄ່ າ. ໂທຫາຝ່ າຍບໍ ິລການສະມາິຊກທ່ີ ໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (TTY: 711). Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih (TTY: 711).